Pediatric Critical Care Practice Questions

Q: A 6-year-old child has a foreign body in the trachea. What is the best initial management?

Heimlich's maneuver. **Explanation:** The primary goal in a child with a suspected foreign body (FB) airway obstruction is the immediate relief of the mechanical blockage. **1. Why Heimlich’s Maneuver is correct:** The **Heimlich maneuver (subdiaphragmatic abdominal thrusts)** is the standard initial management for children over 1 year of age with a complete airway obstruction. It works by elevating the diaphragm, which increases intrathoracic pressure and creates an "artificial cough," forcing air out of the lungs to expel the foreign body from the trachea or larynx. **2. Why other options are incorrect:** * **Cardiac massage:** This is indicated for cardiac arrest (Pulselessness). While airway obstruction can lead to arrest, the immediate priority is clearing the airway. * **Intubation:** This is contraindicated as an initial step because the tube may push the foreign body deeper into the tracheobronchial tree, worsening the obstruction. It is only considered if basic maneuvers fail and the airway must be bypassed. * **Oxygen mask with IPPV:** Positive pressure ventilation is ineffective if the airway is mechanically blocked; it may also push the object further down. **Clinical Pearls for NEET-PG:** * **Age-specific management:** * ** 1 year (Children/Adults):** Heimlich maneuver. * **Gold Standard Diagnosis:** Rigid Bronchoscopy is the definitive method for both diagnosis and removal of a tracheobronchial FB. * **Most common site:** Right main bronchus (due to it being wider, shorter, and more vertical). * **Classic Triad:** Sudden onset of coughing, wheezing, and diminished breath sounds.

Q: A 7-year-old male child was brought to the EMR 6 hours after a burn and was having 22% BSA burns. On examination, cool extremities, BP - 92/50mmHg, PR - 56 BPM. Urine output since burn episode: 30ml. What is the next step in management?

Give crystalloid bolus of 10-20 ml/kg. ***Give crystalloid bolus of 10-20 ml/kg*** - Child presents with **hypovolemic shock** (cool extremities, hypotension, bradycardia, oliguria) - Signs indicate inadequate initial resuscitation despite 6 hours post-burn - Immediate management: **rapid crystalloid bolus of 10-20 ml/kg** (Ringer's lactate or normal saline) over 20-60 minutes - After stabilization, continue calculated Parkland formula resuscitation - Target urine output: **1-2 ml/kg/hr** in children *Give a colloid bolus* - Colloids (albumin, plasma) are **not first-line** in initial burn resuscitation - Crystalloids (Ringer's lactate) are preferred initially due to better efficacy and lower cost - Colloids may be considered later if crystalloid requirements are excessive *Give bolus at 30ml/kg/hr* - This rate is **excessively high** and inappropriate - Risk of fluid overload, pulmonary edema, and compartment syndrome - Standard bolus is 10-20 ml/kg given rapidly, not as an hourly rate *Surgical Intervention* - Not the **immediate priority** in shock management - **Resuscitation before surgery** is the principle in trauma care - Surgical debridement/escharotomy may be needed later after stabilization

Q: Which of the following is not a correct match for ABCD according to pediatric advanced life support?

Dehydration. ***Dehydration*** - In the mnemonic **ABCD** used in **Pediatric Advanced Life Support (PALS)** and basic life support (BLS), D stands for **Disability** (neurological status/deficit), not Dehydration. - Assessing **Disability** involves evaluating the infant's or child's neurological status using tools like the **AVPU scale** or **Glasgow Coma Scale (GCS)**. *Airway* - A stands correctly for **Airway** in the **ABCD** approach, focusing on ensuring a patent passage for breathing. - This step involves opening the airway using maneuvers like the **head tilt/chin lift** (for trauma absence) or **jaw thrust** (for suspected trauma). *Breathing* - B stands correctly for **Breathing**, which assesses the presence and adequacy of respiratory effort. - Management includes providing rescue breaths, using devices like a **bag-mask device**, and determining the need for **intubation**. *Circulation* - C stands correctly for **Circulation**, which evaluates heart rate, pulse strength, capillary refill time, and skin color. - Interventions include initiating **chest compressions** if a pulse is absent or too slow/weak, and managing **shock** (e.g., fluid resuscitation/medications).

Q: Which of the following are advantages of endotracheal intubation, in a child requiring pediatric advanced life support? I. Inspiratory time can be controlled II. Positive end-expiratory pressure can be provided III. Peak expiratory pressure can be controlled IV. Reduced risk of aspiration of gastric contents Select the correct answer using the code given below :

I, II and IV. ***I, II and IV*** - Endotracheal intubation allows for precise control of **inspiratory time**, optimizing ventilation for the child's respiratory mechanics. - It enables the application of **positive end-expiratory pressure (PEEP)**, which helps maintain alveolar patency and improves oxygenation. - An endotracheal tube provides a sealed airway, significantly **reducing the risk of aspiration** of gastric contents into the lungs. *II, III and IV* - While PEEP can be provided and aspiration risk is reduced, endotracheal intubation primarily controls **peak inspiratory pressure**, not peak expiratory pressure. - **Peak expiratory pressure** is usually determined by the patient's lung mechanics and the ventilator's exhalation valve settings, not directly controlled by the tube. *I, III and IV* - Endotracheal intubation allows control of inspiratory time and reduces aspiration risk, but it does not directly control **peak expiratory pressure**. - **Peak expiratory pressure** is largely a function of the patient's lung recoil and airway resistance during exhalation. *I, II and III* - Although inspiratory time can be controlled and PEEP can be provided, **peak expiratory pressure** is not a primary parameter controlled by endotracheal intubation. - The main benefits revolve around controlled ventilation and airway protection, not active control over **peak expiratory pressure**.

Q: A child presented to the casualty department with fever, unconsciousness, and papilledema. What is the next step?

Intubation. **Intubation** - The presence of **unconsciousness** indicates a compromised airway and breathing, making immediate **airway management** and **ventilatory support** a priority. - Papilledema, fever, and unconsciousness suggest increased **intracranial pressure** which can lead to brainstem herniation and respiratory arrest, necessitating **controlled ventilation** to reduce CO2 and ICP. *Oxygenation* - While **oxygenation** is critical, it is often insufficient alone in an unconscious patient with a compromised airway. - **Intubation** ensures a patent airway and delivers controlled oxygenation and ventilation more effectively than oxygenation via mask in this situation. *CT scan* - A **CT scan** is a diagnostic tool, but it should only be performed after the patient is **stabilized** hemodynamically and respiratory-wise. - Transporting an **unconscious** patient with potential increased ICP for a CT scan without securing the airway carries significant risks. *All of the options* - While all listed steps are important in managing a child with these symptoms, **intubation** (airway and breathing stabilization) is the **most immediate and critical next step**. - The sequence of medical interventions follows the **ABC (Airway, Breathing, Circulation)** protocol, making airway management the top priority before diagnostics or other treatments.

Q: How is catecholamine resistant shock managed in children?

Hydrocortisone. ***Hydrocortisone*** - **Hydrocortisone** is the primary treatment for catecholamine-resistant shock in children by addressing the underlying mechanism of receptor unresponsiveness. - It works by **upregulating adrenergic receptors** on vascular smooth muscle, restoring sensitivity to endogenous and exogenous catecholamines. - Additionally provides anti-inflammatory effects and treats relative adrenal insufficiency, which is common in prolonged shock states. - **Standard dosing:** 50-100 mg/m² or 1-2 mg/kg every 6 hours in pediatric shock. *Nor-adrenaline* - **Nor-adrenaline** is a potent catecholamine (alpha and beta agonist) already used in shock management. - In catecholamine-resistant shock, adrenergic receptors are **desensitized or downregulated**, making additional catecholamines less effective. - This is part of the existing therapy that has failed, not the solution to resistance. *Activated protein-C* - **Activated protein-C** (drotrecogin alfa) was used in severe sepsis but has been **withdrawn from the market** due to lack of efficacy and increased bleeding risk. - Not recommended in current pediatric shock guidelines. - Does not address catecholamine receptor unresponsiveness. *Vasopressin* - **Vasopressin** is an important adjunctive agent for catecholamine-resistant shock, acting through **V1 receptors** (non-adrenergic pathway). - Provides vasoconstriction when adrenergic receptors are unresponsive, making it useful in refractory cases. - However, it does not restore catecholamine receptor sensitivity—it bypasses the problem rather than correcting it. - **Hydrocortisone** is preferred as the primary intervention because it addresses the underlying receptor dysfunction, while vasopressin serves as an alternative vasopressor pathway.

Q: What is the dose of adrenaline given to a child with cardiac arrest?

0.1 ml/kg of 1:10000 solution. ***0.1 ml/kg of 1:10000 solution*** - The recommended dose of **adrenaline** (epinephrine) for **pediatric cardiac arrest** is **0.01 mg/kg IV/IO**, which translates to **0.1 ml/kg of a 1:10,000 solution** (0.1 mg/ml). - This is the **standard concentration** recommended by **AHA PALS guidelines** and international resuscitation protocols for intravenous/intraosseous administration during cardiac arrest. - The 1:10,000 dilution provides the correct dose in an appropriate volume that is safe for rapid IV/IO bolus administration. *0.01 ml/kg of 1:10000 solution* - This volume would deliver only **0.001 mg/kg**, which is a **ten-fold underdose** of adrenaline. - This insufficient dose would fail to achieve the necessary **vasoconstrictive** and **inotropic effects** required during cardiopulmonary resuscitation. *0.01 ml/kg of 1:1000 solution* - While this delivers the correct dose (0.01 mg/kg), the **1:1000 concentration** (1 mg/ml) is typically reserved for **intramuscular** or **subcutaneous** administration (e.g., anaphylaxis). - Using 1:1000 solution IV/IO requires extreme caution due to the high concentration and risk of **dosing errors**; standard resuscitation protocols specify 1:10,000 for IV/IO use. *0.1 ml/kg of 1:1000 solution* - This represents a **ten-fold overdose** (0.1 mg/kg) of adrenaline. - Such an excessive dose can cause severe adverse effects including **severe tachyarrhythmias**, profound hypertension, **myocardial ischemia**, and increased myocardial oxygen demand, which are dangerous during cardiac arrest.

Q: A 9 year old girl was admitted for dialysis. On laboratory examination her potassium levels were 7.8 mEq/L. Which of the following would quickly lower her increased potassium levels -

IV Glucose and insulin. ***IV Glucose and insulin*** - **IV glucose and insulin** rapidly shifts potassium from the extracellular to the intracellular compartment by stimulating the Na-K-ATPase pump, making it the **most effective immediate treatment** for severe hyperkalemia. - This therapy acts **within 15-30 minutes** to lower serum potassium levels by 0.5-1.5 mEq/L, which is crucial in emergency situations with life-threatening hyperkalemia. - **Onset: 15-30 minutes** | **Duration: 4-6 hours** *IV calcium gluconate* - **IV calcium gluconate** does not lower serum potassium levels but rather **stabilizes the cardiac membrane** by antagonizing the arrhythmogenic effects of hyperkalemia. - It is an important **first-line treatment** when cardiac toxicity (peaked T waves, widened QRS) is present or imminent, providing immediate cardioprotection **within 1-3 minutes**. - However, it **does not reduce** the total body potassium load and must be followed by definitive treatments. *IV NaHCO3* - **IV sodium bicarbonate** can help shift potassium intracellularly, particularly in cases of hyperkalemia associated with **metabolic acidosis**, but its effect is **slower and less predictable** than insulin and glucose. - Its primary role is to correct acidosis, which secondarily contributes to potassium shift. - **Onset: 30-60 minutes**, making it **not the fastest** option for direct potassium reduction. *Oral kayexalate in sorbitol* - **Kayexalate** (sodium polystyrene sulfonate) is a **cation-exchange resin** that exchanges potassium ions for sodium ions in the gastrointestinal tract, leading to potassium excretion. - This method is **slow-acting** (requires **hours to take effect**) and is therefore not suitable for immediate management of critically high potassium levels like 7.8 mEq/L. - It removes potassium from the body permanently but is not an emergency treatment.

Question 1

A 6-year-old child has a foreign body in the trachea. What is the best initial management?

Accepted Answer

Heimlich's maneuver

Answer

Cardiac massage

Answer

Intubation

Answer

Oxygen mask with intermittent positive pressure ventilation (IPPV)

Question 2

A 7-year-old male child was brought to the EMR 6 hours after a burn and was having 22% BSA burns. On examination, cool extremities, BP - 92/50mmHg, PR - 56 BPM. Urine output since burn episode: 30ml. What is the next step in management?

Accepted Answer

Give crystalloid bolus of 10-20 ml/kg

Answer

Give a colloid bolus

Answer

Give bolus at 30ml / kg / hr

Answer

Surgical Intervention

Question 3

Which of the following is not a correct match for ABCD according to pediatric advanced life support?

Accepted Answer

Dehydration

Answer

Circulation

Answer

Airway

Answer

Breathing

Question 4

Which of the following are advantages of endotracheal intubation, in a child requiring pediatric advanced life support?
I. Inspiratory time can be controlled
II. Positive end-expiratory pressure can be provided
III. Peak expiratory pressure can be controlled
IV. Reduced risk of aspiration of gastric contents

Select the correct answer using the code given below :

Accepted Answer

I, II and IV

Answer

II, III and IV

Answer

I, III and IV

Answer

I, II and III

Question 5

An unconscious child is brought to the casualty. What is the correct sequence of the management?

Accepted Answer

Airway, Breathing, Circulation

Answer

Circulation, Airway, Breathing

Answer

Breathing, Circulation, Airway

Answer

Circulation, Breathing, Airway

Question 6

A child presented to the casualty department with fever, unconsciousness, and papilledema. What is the next step?

Accepted Answer

Intubation

Answer

Oxygenation

Answer

CT scan

Answer

All of the options

Question 7

Swiping of the oral cavity should not be done in foreign body aspiration in children because:

Accepted Answer

Leads to inadvertently pushing the foreign body deep into the respiratory system

Answer

It can trigger vomiting and aspiration

Answer

It is not effective in removing foreign bodies from children

Answer

It may cause trauma to the oral cavity and throat

Question 8

How is catecholamine resistant shock managed in children?

Accepted Answer

Hydrocortisone

Answer

Nor-adrenaline

Answer

Activated protein-C

Answer

Vasopressin

Question 9

What is the dose of adrenaline given to a child with cardiac arrest?

Accepted Answer

0.1 ml/kg of 1:10000 solution

Answer

0.1 ml/kg of 1:1000 solution

Answer

0.01 ml/kg of 1:1000 solution

Answer

0.01 ml/kg of 1:10000 solution

Question 10

A 9 year old girl was admitted for dialysis. On laboratory examination her potassium levels were 7.8 mEq/L. Which of the following would quickly lower her increased potassium levels -

Accepted Answer

IV Glucose and insulin

Answer

IV NaHCO3

Answer

Oral kayexalate in sorbitol

Answer

IV calcium gluconate

Pediatric Critical Care — MCQs

Pediatric Critical Care — MCQs

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